Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Teaching & Learning


The purpose of this study was to develop substantive theory regarding decision making by the novice nurse in a rural hospital setting. Interviews were guided by the following research questions: What cues were used by novice rural registered nurses in order to make clinical decisions? What were the sources of feedback which influenced subsequent decision making for processing of cues?

Theory development was based on an in-depth investigation of 12 novice nurses practicing in rural critical access hospitals in a North Central State. This study consisted of face to face interviews with 12 registered nurses, nine of whom were observed during their work day. Eleven of the 12 participants were interviewed a second time, during which they reviewed their transcripts and the emerging themes and categories as a method of member checking. Directors of nursing from the research sites and rural hospitals not involved in the study, experienced researchers, and nurse educators facilitated triangulation of the findings.

This study revealed novice nurses were able to identify varying cues for decision making, including patient vital signs and patient assessments. These cues were often compared to the nurses' previous encounters with the patients through the health care system or through contact in the community. Familiarity with a diagnosis, such as chest pain, was explained by participants as knowledge they had gained during formal education and in patient encounters within their first year of practice. Where cues were more subtle, participants turned to coworkers to confirm or deny their hunches and to help them decide on actions. They did not, as has been suggested in the literature, turn back to textbooks or linear decision making models to help them analyze the situations.

Recommendations were made for nurse educators, who have been tasked with facilitating critical thinking in all nursing students in the preparation of the graduate generalist practitioner. Researchers have been provided suggestions for future exploration of decision making processes in rural nursing. Those who practice rural nursing in either leadership or supportive work roles were given recommendations related to mentoring the new nurse while fostering decision making skills.